Nurses’ perceptions about the patient safety climate in Primary Health Care

Objective:
 to evaluate the patient safety climate in Primary Health Care from the perspective of nurses working in the services. 
Method:
 a quantitative and cross-sectional study conducted with 148 nurses from a municipality in the state of São Paulo. The Brazilian version of the Primary Care Safety Questionnaire Survey and personal, professional, and organizational performance variables (intention to stay at work, job satisfaction, care quality, and frequency of incidents) were used. Parametric and non-parametric comparison tests and Spearman’s correlation coefficient were performed, considering a 5% significance level. 
Results:
 the safety climate was positive, varying from 4.52 to 5.33 and differing across districts for workload (p=0.0214) and leadership (p=0.0129). The safety climate professional variables and dimensions differed in relation to the frequency of incidents. Teamwork and safety and learning system were strongly correlated with job satisfaction and moderately with perceived care quality. 
Conclusion:
 teamwork and safety and learning system stood out for their positive correlations with job satisfaction and care quality. A positive safety climate favors the involvement of Primary Care nurses to develop improvement plans aligned with the National Patient Safety Program.


Introduction
Patient safety is defined as a structure of organized activities that creates cultures, processes, procedures, behaviors, technologies and environments conducive to health care that consistently and sustainably reduce risks and the occurrence of preventable harms (1) .Care quality at all health care levels (1)(2) is influenced by Primary Health Care (PHC), which is considered the main gateway and communication center of the Health Care Network (Rede de Atenção à Saúde, RAS) belonging to the Unified Health System (Sistema Único de Saúde, SUS).
In PHC, the adoption of patient safety precepts is still incipient despite the launch of the National Patient Safety Program (Programa Nacional de Segurança do Paciente, PNSP) in 2013, which established the obligation to implement protocols and strategies guiding actions for safe care in all health services of the country.In 2017, the National Primary Care Policy (Política Nacional de Atenção Básica, PNAB) contributed advances in this theme with a focus on reducing risks and adverse events in PHC services (3)(4) .The term "patient safety" can be strange to PHC professionals since, according to the SUS principles, citizens are understood as protagonists and participants in their care, being called users.However, it is worth noting that it is a taxonomy recognized worldwide for all health services.
Harms to the user arising from unsafe care are therefore a global challenge for managers and public health, as they can cause irreversible disabilities and lead to death (1)(2) .In England, the incidence of harms in PHC was from 35.6 to 57.9 per 100,000 users a year and, for the most part, it was related to problems with diagnosis, followed by issues with drug prescription, and a smaller portion with late referrals for treatments, such that the authors highlighted that most of the incidents can be avoided (5) .
In Brazil, studies on patient safety in PHC indicate that the most common incidents were associated with diagnostic and medication errors, and the contributing factors to these incidents were as follows: failures in care, management and communication with users, with the team and with other RAS levels (6) .In addition to that, they were also associated with administrative errors such as failures involving medical records, incomplete records, loss, misplacement and exchange between users (7) .In addition, personal, organizational and work environment factors, both internal and external, can also influence a negative safety culture (8) .
Creating a sustainable culture that promotes patient safety is a key condition for reducing adverse events in health institutions, as it makes it possible to find structural and systemic weaknesses and, based on them, take action to improve health (1) .A strong safety culture is fundamental to reducing user harm and providing a safe working environment for health workers (1) .
The safety climate is an indirect measure of an organization's safety culture (9) , which involves people's perspectives and beliefs regarding safety policy and services, organizational attitudes, safety supervision and management (10) .The safety climate assessment through specific instruments is an efficient method for diagnosing aspects of the institutional safety culture (11) , which allows strengthening management in terms of planning actions in this direction (12) .
The PHC guidelines are to provide a comprehensive, welcoming, safe and responsive service to the health demands of people, families and communities (3,(13)(14) .
Nurses are professionals who play a central role in the management of teams working in PHC services, through their leadership both in technical/care activities and in the planning and coordination of programs established by laws, statutes and guidelines of the Ministry of Health (Ministério da Saúde, MS) and the professional council (3,(14)(15) .

It is noted that effective leadership is fundamental
to establishing an institutional culture focused on patient safety and understanding that there may be flaws and potential errors in the care production process, which need to be evaluated and corrected (16)(17)(18) .In view of the above, in this study the objective was to evaluate the patient safety climate in PHC from the perspective of nurses working in the services.

Method Type of study
A quantitative and cross-sectional study following the recommendations outlined in STrengthening the Reporting of Observational studies in Epidemiology (STROBE) (19) .It is noted that the patient safety climate in the PHC context will be analyzed from the nurses' perspective, based on personal, professional, and organizational performance variables.

Locus
The study was carried out in a large municipality with an estimated population of

Selection criteria
Nurses who worked in coordination and assistance of the HCs and with a minimum experience of six months were considered.Professionals absent due to vacation or other leaves of absence were excluded.

Sample
The sample size was determined considering the sample calculation methodology to estimate a proportion (21) .The calculation assumed a proportion equal to 0.50, representing the maximum variability of the binomial distribution, 5% sampling error, 5% significance EACS]); whether the team was complete; and whether the professionals had another employment contract.It is worth highlighting that the teams mentioned are organized by the PNAB (3) .

The safety climate variable was extracted from
the Brazilian version of the Primary Care Safety Questionnaire (PC-SafeQuest) (22) and aims to assesss the user's perception of the safety climate in PHC.It consists of 28 items distributed across five dimensions: workload (three items) shows impaired performance due to excessive workload, inadequate staffing, time constraints, and the professionals' expectations when working under pressure; communication (five items) covers the degree to which discussions between team members are open and honest, and whether the professionals feel free to question management decisions; leadership (five items) assesses whether the leaders are open to suggestions for improvements and attitudes towards formal rules and procedures; teamwork (seven items) refers to the perception of its importance and the level of mutual respect and support within teams; and safety and learning system (eight items) assesses the degree to which the practices encourage communication of significant events and the existence of procedures to prevent them (23) .These dimensions are evaluated using a Likert scale with the following options: "Not at all (1 point)"; "To a very limited extent (2 points)"; "To a limited extent (3 points)"; "Moderately (4 points)"; "To a considerable extent (5 points)"; "To a significant extent (6 points)"; and "Completely (7 points)".The score is calculated by the mean value of the answers to each item, and the higher the score, the more positive the professional's perception of the safety climate.For the current study, a positive safety climate was considered when the mean scores were equal to or greater than Rev. Latino-Am.Enfermagem 2024;32:e4092.
four points; and mean scores lower than four classified as a negative safety climate.PC-SafeQuest is one of the PHC climate assessment instruments recognized for its practicality, acceptability, and possibility of identifying weak points that deserve to be investigated and modified (11) .
The organizational performance variables assessed were as follows: the professional's intention to stay in the job the following year; perception about the care quality offered to the users in their work environment; job satisfaction; and healthcare-related incidents.The first two variables were evaluated on a scale that varies from zero to ten points, and the closer to ten, the better the perception of care quality and the greater the intention to stay on the job.
The "professional satisfaction" variable about their current position at work was measured using the Job satisfaction subscale, extracted from the Brazilian version of the 2006 Safety Attitudes Questionnaire (SAQ) -Short form (24) .It is noted that this subscale consists of five items, namely: 1.I like my job; 2. Working here is like being part of a big family; 3.This is a good place to work; 4. I am proud to work in this area; and 5. Morale (state of mind/mood) in this area is high.These items were evaluated using a Likert scale with the following options: "I totally disagree" (zero points); "I partially disagree" (25 points); "Neutral" (50 points); "I partially agree" (75 points); "I totally agree" (100 points); and the "Not applicable" option for items without a score.The score for each domain is obtained by adding the scores and dividing by the number of questions answered, excluding those with a "Not applicable" answer.
Values equal to or above 75 points represent satisfied professionals at work.Finally, the "healthcare-related incidents" variable covered the following: a) failure to identify the user in procedures and exams; b) failure to identify the user in the consultation and medical records; c) non-adherence to hand hygiene; and d) failure in communication between professionals and users.Any deviation in care that poses a risk of harm to the patient, such as avoidable errors, events, or dangers, were considered incidents (14) .The participants were asked to report the frequency of these incidents in their work unit during the last month, with the following answer options: "Never" (1 point); "Rarely" (2 points); "Frequently" (3 points); and "Very frequently" (4 points).

Data collection
One of the authors carried out the collection in person at the HCs.After accepting the invitation, the nurses who met the inclusion criteria to participate in the study received an envelope containing the instruments, two printed copies of the Free and Informed Consent Form (FICF), a pen and a seal.
Each nurse agreed on the best day and time to answer the instruments.They also agreed to return them if they could not answer them at that moment.The instruments were self-answered, with the author only available for possible doubts.
The collection was carried out using the Brazilian version of PC-SafeQuest (22) , the Job Satisfaction subscale extracted from the Brazilian version of the Safety Attitudes Questionnaire(SAQ) (24) , and a form with personal and professional variables, organizational performance and frequency of incidents, previously prepared and subjected to content validity by a group of judges.

Data analysis
The data collected were entered into an Excel spreadsheet, with double-checking and validation of the For the correlation analyses between the PC-SafeQuest scores and the other quantitative variables, Spearman's correlation coefficient was applied, with values from zero to 0.29 considered as weak in magnitude, from 0.30 to 0.49 as moderate in magnitude, and values equal to or above 0.50 as of strong magnitude (25) .

Results
The sample included 148 nurses with a mean age of 38.81 years old (SD=7.98),mean experience in PHC of 9.81 years (SD=7.43),and 5.65 years (SD=4.14) in the current team.Table 1 presents other characteristics.In the comparison analyses between the PC-SafeQuest dimensions and personal (gender, marital status) and professional (role in the HC and team completeness) variables, it was verified that they differ in terms of role and completeness of the team.Nurses in the role of coordinators reported higher scores for all PC-SafeQuest dimensions when compared to clinical nurses, with statistically significant differences for the communication (p=0.0093),teamwork (p=0.0116) and safety and learning system (p=0.0030)dimensions and the total score (p=0.0035).
In turn, when comparing PC-SafeQuest to the completeness of the team, it was verified that those who reported working with an incomplete team presented higher scores for the leadership (p=0.0111) and teamwork (p=0.0163)dimensions when compared to those who reported working with a complete team.
Regarding nurses' perception of the safety climate across the HDs, there were significant statistical differences for the workload and leadership dimensions and total score, as shown in Table 2.
Regarding the frequency of healthcare-related incidents, the nurses reported 9.52% of frequent or very frequent occurrences for failure to identify the user in procedures and exams, 23.29% for failure to identify the user in consultations and medical records, 29.73% for non-adherence to hand hygiene and 64.19% for failure in communication between professionals and users.The comparisons in relation to the personal and professional variables, care quality, job satisfaction, and PC-SafeQuest dimensions with the frequency of incidents are presented in Table 3.

Another aspect analyzed in the current study refers
to the assessment of the existence of a correlation between the PC-SafeQuest dimensions and personal, professional, and organizational performance variables, which resulted in correlations of strong, moderate, and weak magnitude (Table 4).

Discussion
The sample of nurses in this study comprised young adults, most of whom were women and responsible for care activities in the different centers and HDs.The and efficient care (2) .
In this study, a certain mismatch in the availability of human resources was identified, so the majority answered that their work team was not complete; however, they reported offering good care quality to the users, job satisfaction, and intention to stay on the job.On the other hand, a study carried out in Spain with PHC nurses also highlighted problems related to the adequacy of human resources, such as an insufficient number of professionals to carry out the work, insufficient time and opportunities to discuss care-related issues, and insufficient support services that allow nurses to devote more time to the users, which were highlighted as weaknesses in the nurses' practice environment in PHC to ensure the care quality provided (26) .
The nurses reported a positive perception of the safety climate, whose values are close to studies carried out in the United Kingdom (9,(27)(28) and Ireland (29) , which used the same instrument.These are compared to studies carried out with PHC health professionals using other instruments, such as the Medical Office Survey on Patient Safety Culture in Greece (2) and in Kuwait (30) and the Hospital Survey on Patient Safety Culture in Oman (17) .
The favorable safety climate indicates that the professionals perceive that the coordination of the units is focused on safeguarding the care procedures and the professionals' safety through clear, participative communication and actions aligned with an institutional policy devoted to safety and quality (31) .This study identified statistically significant differences in the perception of the safety climate between coordinating nurses and those responsible for user assistance activities, in which the coordinators attributed higher scores to the communication, teamwork, safety, and learning system dimensions and the PC-SafeQuest total score.
These dimensions were also evaluated in a study in England (9) with PC-SafeQuest, showing that managers classified the safety climate as significantly more positive than non-managers.The same is true with another study in Scotland (27) , which obtained statistically significant differences in the perception of the safety climate among management professionals in relation to other workers.Both studies conclude that the variation in the safety climate perception among certain groups of professionals should be aligned to build a solid safety culture (9,27) .
An unexpected result in this study was that the nurses who reported working with an incomplete team had more positive perceptions about the leadership and teamwork dimensions when compared to those who working with a complete team.As this is a study with a specific sample of nurses, no other surveys were found for comparison purposes; one of the possible reasons is the fact that, regardless of whether or not they exercise the unit coordinator role, these nurses are team leaders and are able to develop collaborative work with autonomy to prioritize the unit's service demands.One study highlights that effective leadership is fundamental for developing a safety culture within an organization (16) .
It is noted that working with an incomplete team can impair patient safety due to work overload (18) .A national study conducted with PHC nurses from several Brazilian regions identified that the professionals in Family Health teams are exposed to physical and mental workloads resulting from excessive demands and insufficient professionals, which can compromise their health and care quality (32) .A study in England highlights the relationship between increased workload and exposure to stress among health professionals involved in clinical practice and management (9) .
The for care continuity (33) .
Nurses with longer experience in PHC, greater intention to stay in the job, more satisfaction at work, and better perceptions about care quality and the safety climate reported lower frequencies of healthcare-related incidents.Although there is no consensus in the literature about these incidents in PHC, several authors emphasize that they should not be associated with those in hospital care.The work guidelines, structure, and dynamics of care differ greatly in PHC, and it becomes crucial to identify incidents reported by professionals based on the experience of their everyday practice (7) .
A lower frequency of failures to identify the user in procedures and exams was identified, related to nurses' greater intention to stay on the job, as well as the failure to identify the user in the consultation and medical records, which was also less frequent for nurses who reported job satisfaction, better perception about care quality and longer experience in PHC.Longer experience in the current team and in PHC and a better perception of care quality were also related to fewer failures in adhering to hand hygiene.It was verified that a better perception of quality and satisfaction with work are related to a lower frequency of communication failures between professionals and users.

Correct identification of the users in all service
environments circulating within the HC is a basic and indispensable procedure to avoid errors.However, this is not routine in PHC, given that failures in medical records have been reported as contributing factors to errors, especially in FHS units, where the arrangement in the family medical record format, comprised of multiple users, contains flaws in its organization and maintenance due to handling and storage (6) .
In this study, the results showed that the lower permanent education programs should be valued in health institutions (14) .A study that evaluated the as well as promoting self-efficacy and safety behaviors and reducing burnout in these latter's work (34) .
The importance of studies on this topic in PHC is highlighted in the context of the current health programs and policies, as such services incorporate this prerogative as care coordinators and organizers within the RAS scope.
The results of the current study are motivating due to the novelty of the theme in PHC, in addition to being Managers, professionals, and users will be able to plan and implement actions to strengthen the dimensions that contribute to a positive safety climate and reevaluate those that require continuous improvement, aligned with the PNSP, with a view to strengthening the safety culture and procedures in PHC.It is recommended that studies be carried out, given the relevance and scarcity of studies addressing patient safety in PHC.
level, and a population of 249 nurses.The calculation resulted in a minimum sample of 151 participants.The sample was divided proportionally across the districts according to the population of nurses in each district, with 25 in the East District, 31 in the Northwest District, 27 in the North District, 29 in the Southwest District, and 39 in the South District.The participants were selected through a cluster sampling scheme and stratified according to districts.The numbers of HCs that made up the study were as follows: ten in the North District; 14 in the South; eight in the East; 11 in the Northwest; and 12 in the Southwest.It is worth noting data collection interruption due to the COVID-19 pandemic, especially with regard to the East District (the last collection site) due to the lack of access to the HCs and the unavailability of nurses.Thus, eventually, it was possible to obtain a sample comprised of 148 nurses: 16 in the East District (out of the 25 planned); 31 in the Northwest; 30 in the North (out of the 27 planned); 32 in the Southwest (out of the 29 planned); and 39 in the South.Therefore, the number of participants from the North and Southwest Districts exceeded the predicted proportional sample.Variables Personal variables of age, gender and marital status were considered.The professional variables were the following: experience time in the current team and PHC; role in the HC in relation to coordination or assistance position; number of teams in the HC; type of team in which they worked (Family Health Strategy [FHS] or Basic Health Unit [BHU] and Community Health Agents Strategy [Estratégia de AgentesComunitários de Saúde, database, and analyzed using the Statistical Analysis System (SAS) software, version 9.4, and the Statistical Package for the Social Sciences (SPSS), version 23.A 5% significance level was assumed in the analyses.Descriptive statistics were performed by calculating absolute and relative frequencies for the qualitative variables and of central tendency and dispersion measures for the quantitative ones.The ANOVA model was applied to analyze the comparisons between districts regarding the PC-SafeQuest scores, followed by Tukey's post-test or the Kruskal-Wallis test, followed by Dunn's posttest, according to data distribution.The comparisons considering gender, marital status, role in the HC, and team composition in relation to the PC-SafeQuest scores and between the categories for frequency of occurrence of incidents related to the quantitative variables were carried out using the Student's unpaired t test or the Mann-Whitney test, according to data distribution.In these analyses, the frequency of incidents reported by the nurses was grouped into the "Never/Rarely" and "Frequently/Very frequently" answer options.Data distribution was assessed using the Shapiro-Wilk test, and variances homogeneity by Levene's test.
nurses' extensive experience in PHC and the current team, coupled with only one employment contract, indicates that they are skilled professionals who are duly prepared and committed to performing their activities.With time in service, the professionals can understand the development of their work, available resources, and interactions with the work team in a collaborative process responsible for delivering safe the frequency of failures to identify the user in the consultation and medical records, the more positive the perception of the safety climate by nurses for the leadership, teamwork, and safety and learning system dimensions, although not for the workload and communication dimensions.It is also interesting to note that the lower frequency of communication failures between professionals and users resulted in a more positive perception of the safety climate for all PC-SafeQuest dimensions.The assessment of correlations between the PC-SafeQuest dimensions and personal and professional variables showed that the safety, learning system, and teamwork dimensions resulted in correlations of strong magnitude with job satisfaction and moderate with the care quality perception.The communication and leadership dimensions resulted in a moderate correlation with job satisfaction.In turn, the leadership and workload dimensions moderately correlated with the perception care quality.The World Health Organization emphasizes leadership training as one of the factors to ensure improvements in healthcare safety and, therefore, impact of a training program on leadership in patient safety among nurses in the role of manager and clinical nurses in a hospital institution from China resulted in an improvement in nurse-managers' self-efficacy and leadership behaviors and clinical nurses' safety behaviors, able to encourage leaders to strengthen the safety culture in such health care points, as well as signaling that coordinators and clinical nurses should value the workload and communication dimensions for the proper functioning of the work done and of the team relationships in the PHC context.As a limitation, there is data collection interruption in the East District due to the COVID-19 pandemic, which reduces the representativeness of this district.In addition to that, the number of participants from the North and Southwest districts did not follow what had been planned in the sample calculation.ConclusionThe perception of the safety climate by nurses in PHC was positive and differed across HDs for the workload and leadership dimensions.The professional variables and dimensions of the safety climate differed in relation to the frequency of incidents, mainly regarding failures in communication between professionals and users, and the identification of the user in the consultation and medical records.The dimensions relevant to teamwork and safety and the learning system showed correlations of strong magnitude with job satisfaction and moderate magnitude with the care quality perception.
The institution's Research Ethics Committee approved the study under Opinion No. 3,179,811, by the recommendations set forth in Resolution No. 466/12 of the National Research Ethics Council.

Table 1 -
Characterization of the health centers and nurses by health district (n * = 148).São Paulo, Brazil, 2020Rev.Latino-Am.Enfermagem 2024;32:e4092.Regarding the organizational performance variables, the nurses reported a mean score of 75.29 (SD=21.03)forjob satisfaction, 8.08 (SD=2.91)forintention to stay on the job, and 7.68 (SD=1.38)forperception about the care quality offered to the users.As for the perception of the safety climate, the mean scores for the dimensions were as follows: * n = Sample; † % = Percentage; ‡ FHS = Family Health Strategy; § EACS = Estratégia de Agentes Comunitários de Saúde (Community Health Agents Strategy); || BHU = Basic Health Unit
(continues on the next page...) * PC-SafeQuest = Primary Care Safety Questionnaire; † n = Sample; ‡ Failure to identify the user in procedures and exams; § Failure to identify the user in the consultation and medical records; || Non-adherence to hand hygiene; ¶ Failure in communication between professionals and users; ** SD = Standard Deviation; † † IQR = Interquartile Range; ‡ ‡ p-value = Significance probability; § § Never/Rarely; |||| Mann-Whitney test -Comparisons based on the median and IQR; ¶ ¶ Frequently/Very frequently; *** Unpaired Student's t test -Comparisons based on mean and standard deviation